Assess whether a provider should be suspended pending SIU (432ffc)

Situation

SIU investigator owns a provider should be inside a Medicare Advantage claims shop with ACH return-reason code R10 spike as the only packet. A mortgage occupancy affidavit contradicting utility records is what changed the clock for this Fraud Detection Claims and Benefits Fraud file.

Decision

SIU investigator in a Medicare Advantage claims shop must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using ACH return-reason code R10 spike after a mortgage occupancy affidavit contradicting utility records.

Hypotheses to test

• ACH return-reason code R10 spike reads as Remove access or reverse the item once a mortgage occupancy affidavit contradicting utility records is lined up to the same Fraud Detection population.
• ACH return-reason code R10 spike is closer to Temporary compensating control after a mortgage occupancy affidavit contradicting utility records; Remove access or reverse the item would over-claim this Claims and Benefits Fraud extract.
• Approve a documented exception is still live in ACH return-reason code R10 spike for SIU investigator in a Medicare Advantage claims shop.
• ACH return-reason code R10 spike is missing the fact SIU investigator needs after a mortgage occupancy affidavit contradicting utility records; stop this Fraud Detection close.

Analysis required

• Test a one-off dispute against the first edge of a scheme around a provider should be.
• Check mule or round-trip markers in ACH return-reason code R10 spike.
• Map typology and hold authority SIU investigator actually has in a Medicare Advantage claims shop.
• For this Fraud Detection Claims and Benefits Fraud file, read ACH return-reason code R10 spike against a mortgage occupancy affidavit contradicting utility records and write the one fact that would move a provider should be for SIU investigator.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Claims and Benefits Fraud packet (ACH return-reason code R10 spike after a mortgage occupancy affidavit contradicting utility records). The follow-on Claims and Benefits Fraud action is what SIU investigator does next: implement the option, assign an owner, and log the missing fact.